The environmental impact of health care for musculoskeletal conditions: A scoping review

Background Health care has significant environmental impact. We performed a scoping review to map what is known about the environmental impact of health care for musculoskeletal conditions. Methods We included published papers of any design that measured or discussed environmental impact of health care or health support services for any musculoskeletal condition in terms of climate change or global warming (e.g., greenhouse gas emissions it produces). We searched MEDLINE and Embase from inception to 2 May 2022 using keywords for environmental health and musculoskeletal conditions, and performed keyword searches using Google and Google Scholar. Two independent reviewers screened studies. One author independently charted data, verified by a second author. A narrative synthesis was performed. Results Of 12,302 publications screened and 73 identified from other searches, 122 full-text articles were assessed for eligibility, and 49 were included (published 1994 to 2022). Of 24 original research studies, 11 measured environmental impact relating to climate change in orthopaedics (n = 10), and medical aids for the knee (n = 1), one measured energy expenditure of laminar versus turbulent airflow ventilation systems in operating rooms during simulated hip replacements and 12 measured waste associated with orthopaedic surgery but did not relate waste to greenhouse gas emissions or environmental effects. Twenty-one editorials described a need to reduce environmental impact of orthopaedic surgery (n = 9), physiotherapy (n = 9), podiatry (n = 2) or occupational therapy (n = 1). Four narrative reviews discussed sustainability relating to hand surgery (n = 2), orthopaedic surgery (n = 1) and orthopaedic implants (n = 1). Conclusion Despite an established link between health care and greenhouse gas emissions we found limited empirical data estimating the impact of musculoskeletal health care on the environment. These data are needed to determine whether actions to lower the carbon footprint of musculoskeletal health care should be a priority and to identify those aspects of care that should be prioritised.


Introduction
Climate change is an existential crisis [1]. There is a need to understand the key contributors to climate change to minimise their impacts. Health care results in significant direct and indirect greenhouse gas emissions, commonly termed the 'carbon footprint'. It is responsible for between one to five percent of the total global environmental impacts [2], although the proportion of overall greenhouse emissions due to health care is greater in some countries such as the United States (8.5%) [3], and Australia (7%) [4]. The UK, whose health care greenhouse emissions is responsible for approximately 4% of the UK's footprint, is leading the world in striving for carbon neutral health care by 2040 [5].
The largest contributors to the carbon footprint of health care are generated as part of hospital stays, surgery, pharmaceutical manufacturing and imaging [4,6]. Recent carbon footprint estimates suggest the majority of health care related greenhouse emissions are produced from energy use and the health care supply chain such as manufacturing medical equipment and materials, transport, agriculture and waste disposal [7]. Yet awareness of the carbon footprint generated by different aspects of health care is not yet well appreciated among many health care providers or the general public, delaying efforts to identify and reduce it [8].
Approximately one third of health care is estimated to be of low value or 'wasted' [9][10][11]. For example, there is a large body of evidence attesting to widespread low-value health care practices for common musculoskeletal conditions such as osteoarthritis [12], low back pain [13], hip and knee pain [12], shoulder pain [14][15][16] and sports injuries [17]. Directing efforts towards eliminating these aspects of care would have the dual benefit of reducing harms associated with unnecessary care, and avoiding their harmful effects on the environment.
While the environmental impact of health care in some fields of medicine has been investigated, including treatment of patients with septic shock in intensive care [18], cataract surgery [19] and geriatric medicine [20], there is a paucity of evidence outlining environmental impacts of other types of care. The aim of this scoping review was to map what is known about the environmental impact of health care for musculoskeletal conditions.

Methods
We reported this scoping review in accordance with the recommendations of the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR; [21], see S1 Data).
indices of climate change or global warming such as the amount and type of greenhouse gas it produces [22]. All publication designs were eligible for inclusion, including original research, reviews, or commentaries. We did not impose any date or language restrictions.

Search strategy
We searched electronic databases of MEDLINE and Embase (via Ovid) from inception to 2 May 2022. Our search strategy consisted of combining two concepts: environmental health and musculoskeletal conditions. Internet searches were also performed using Google and Google Scholar between 2 May and 12 May 2022 within the Google Chrome browser. The internet search engines were chosen to ensure a wide range of publications across multiple musculoskeletal disciplines, and combined environmental keywords 'life cycle assessment', 'sustainability', 'environmental sustainability', 'environmental impact' and 'carbon footprint' with terms of 'hand', 'wrist', 'elbow', 'shoulder', 'foot', 'ankle', 'knee', 'hip', 'spine' and 'spinal'. We also used various combinations of the following keywords: 'surgery', 'surgical', 'surgical implant', 'orthopaedic surgery', 'joint arthroplasty', 'joint arthroscopy', 'joint replacement', 'telemedicine' and 'telehealth'. We considered the first 50 Google and Google Scholar results from each set of keywords. The full search strategy is presented in see S2 Data. We also hand searched reference lists of included publications.
All records generated from electronic databases were exported to Covidence (Veritas Health Innovation, Melbourne, Australia) for duplicate removal and screening [23]. Two authors (BM and either RH, GF, CM or RB) independently assessed each title and abstract and then independently screened the full texts of potentially eligible publications to identify those eligible for inclusion. Google and Google Scholar records were independently assessed by one author (BM). Potentially eligible publications were downloaded as full texts and screened by two authors (BM and either RH, GF, CM or RB). Publications not written in English were translated with Google Translate [24]. Conflicts were resolved through discussion. Publications relating to the same primary publication were considered together and counted only once.

Data charting and analysis
For each original research publication, one author (BM) independently charted author/s, year, country, setting, timing of study, study design, topic, aim/s and methods, results and conclusion. Data from editorial publications and narrative reviews were independently charted by one author (BM) for author/s, year, country of author/s, topic, focus and conclusions. Another author (RH, GF or RB) independently verified all data extraction. A narrative synthesis of the papers is presented.

Results
Of 12,302 publications retrieved and screened from electronic databases and 73 publications that were identified and screened using Google, Google Scholar and hand searches of citations, 122 full-text articles were assessed for eligibility and 48 were excluded (Fig 1) Table). Sixteen reports of included publications were collated with an associated primary report and counted as a single unit to prevent duplication of the same record [67-82] (see Tables 1 and S3). Forty-nine primary publications were included in this review .

Overview of included publications
The characteristics and findings of included publications are presented in Table 1 for original research publications and as supplementary materials for included editorials and reviews (see S3 and S4 Tables). Included papers were published from 1994 to 2022, with most published since 2019 (n = 36, 73%).

PLOS ONE
The environmental impact of health care for musculoskeletal conditions: A scoping review The additive manufacturing process was more sustainable for titanium femoral stem manufacturing due to recovery of loose titanium power at the end of the process that can be reused.

PLOS ONE
The environmental impact of health care for musculoskeletal conditions: A scoping review Life cycle assessment Orthopaedic surgery (general, regional and combined anaesthesia) To quantify the carbon dioxide equivalent emissions of three anaesthetic approaches for total knee replacement surgery.
The carbon footprint of knee replacement surgery can be reduced by using low-flow anaesthetic gas and/or local anaesthesia, reducing single-use plastics and oxygen flows during surgery, and collaborating with engineers to improve energy efficiency.

Engineering laboratory
Timing: 2014 to 2015 Life cycle assessment (cradle to gate; case study) Medical aid (knee support brace) To develop a multicriteria decisionmaking model for optimal product selection of 3 types of knee support (elastic, crossed and hinged) using life cycle assessment (LCA) and multi-criteria decision making (MCDM) approaches.
Based on LCA results, elastic knee support production had the lowest environmental impact, followed by the crossed knee support. Polyester was identified as the highest contributor to the environmental impact for each knee support.
The MCDM-LCA model output ranked the elastic knee support as the best, followed by the hinged knee support and then the crossed knee support.
Results differences between LCA and MCDM-LCA approaches were due to the significant weighting of economic and technical criteria for the MCDM-LCA model.
LCA and MCDM approaches can identify knee supports with the lowest environmental impact and can be used to optimise 'eco-design' of new knee support products.
(Continued ) Lowering fresh air influx of laminar air flow (LAF) by 50% significantly lowered energy consumption but did not adversely affect the bacterial or particle counts.
(Continued ) Orthopaedic surgery is a substantial source of waste production in the hospital system. Nearly 3/4 of all waste in the preoperative period can be effectively recycled.
Joint replacement surgery is one of the largest waste producers, but it also has the highest potential for recycling of materials.
(Continued ) To determine the amount of waste from musculoskeletal surgeries from two fiveday audits.
Conducting hospital waste audits may drive a systems approach to reduce waste, and lead to environmentally sustainable health care practices.

PLOS ONE
The environmental impact of health care for musculoskeletal conditions: A scoping review

Study design Topic Aim/s and methods Results Conclusion
Dupuytren's contracture excision (n = 2), ACL repair (n = 1), foraminotomy (n = 1), fasciotomy (n = 1), ankle ligament repair (n = 1), ankle open reduction internal fixation (n = 1), volar wrist repair (n = 1), arthrodesis (n = 1), rotator cuff repair (n = 1) and arthroscopic clavicle repair (n = 1). The study led to the introduction of customised operating kits for total hip replacement surgery that are adapted to the needs of different hospitals and types of surgery in order to reduce the amount of sterile packaging. However, the rationale for these customised operating kits and the calculation of how much waste it would reduce is unclear.

PLOS ONE
The environmental impact of health care for musculoskeletal conditions: A scoping review To identify the amount and type of waste produced by operating rooms in order to reduce the hospitalregulated medical waste so as to achieve environmentally friendly waste management in the operating room.

PLOS ONE
The environmental impact of health care for musculoskeletal conditions: A scoping review

2:
Nine patients from the combination anaesthesia group were analysed because one patient who received nitrous oxide was excluded.

3:
Carbon emissions data did not include heating, ventilation, air conditioning or any surgical equipment. 4: Seven of the 305 patients lived more than 200 miles from the medical centre and were excluded from the analysis.

5:
The central processing-related carbon footprint includes electricity usage for sterilisation and was calculated using data collected from the study institution.

6:
The facility-related carbon footprint was calculated as the sum of the kg CO 2 e produced when using operating room lights, anaesthesia equipment, endoscopy equipment, heating, cooling and the use of ventilation.

7:
Waste-related carbon footprint was calculated as the sum of solid waste derived from positioning, prepping, draping, carpal-tunnel procedure, wound closure and wound dressing. The carbon footprint of solid waste was determined using the conversion factor of 0.199 kg CO 2 e per kg. 8: eCTR requires more instrumentation than oCTR, resulting in fewer trays being sterilised per cycle and thus increasing its sterilisation energy requirements. eCTR also used more electricity compared with oCTR due to longer operating times.

9:
This study also reported data for 481 speech therapy visits from a speech therapy unit, which are outside the scope of this review. 10: Based on the cost of a car being 0.26 kg CO 2 e/km, derived from data by Leduc et al. (2010) [132].

11:
Based on estimates by Lenzen et al. (1999) [133] that reported the cost of a car was 0.86 kg CO 2 e/km.

12:
This study did not perform carbon footprint calculations related to the number of plastic disposables used for each anaesthetic modality, the energy use for heating/ cooling, ventilation, lighting, electricity for anaesthetic machines, surgical instruments, surgical implants, single-use items such as drapes and gloves, and intraoperative imaging.

13:
Six general anaesthesia cases included the use of desflurane, which has a very high carbon footprint compared to other anaesthetic gases. Desflurane significantly skewed the mean total carbon footprint data for general anaesthesia.

14:
The study also included plastic surgery procedures; breast reduction, breast augmentation, implant/expander removal, panniculectomy and abdominoplasty.

15:
A blue wrap recycling program at Hahnemann campus, where collected blue wrap was sewn into charity items, diverted an additional 1.2 tonnes of waste from landfill over a 10-month period.

17:
Additional data were presented for the mean weight of other surgical procedures; ankle ORIF, humerus ORIF, clavicle ORIF, hip hemiarthroplasty and kyphoplasty, but the number of surgeries used to derive these data was not reported.

18:
Fifty-two percent of the total surgical waste (110 grams) was related to surgical screws.

19:
Waste weight data were converted from pounds to kilograms by multiplying figures by 0.454. 20: Contaminated waste items included surgical gloves, personal protective equipment, surgical drapes, tables, sponges, towels, tubing and surgical instruments.

21:
Uncontaminated waste items included paper packaging, plastic packaging and blue polypropylene sterile wrap.

22:
Hospital waste data for 223 non-musculoskeletal surgeries were also recorded for this audit. 23: Data are also available according to musculoskeletal surgery type.

24:
This study also reported an additional waste audit of one total knee replacement, one laparoscopic procedure and one pelviscopic procedure, however, individual data could not be separated. 25: Domestic waste consisted of recyclable dry paper and card (47%), potentially recyclable plastic (47%) and non-recyclable wet paper or card or plastic (6%).

26:
Weight of standard hand surgery custom pack was 2.04 kg.

PLOS ONE
The environmental impact of health care for musculoskeletal conditions: A scoping review Two LCA studies investigated the environmental impact of manufacturing a titanium implant for a knee [95] or hip [104] replacement. Both concluded that additive manufacturing of a prosthesis (building it one layer at a time) is more environmentally sustainable than creating complex geometric shapes using conventional methods (subtractive manufacturing or forging, milling, machining from a solid block of material until the final product is produced). One study reported that additive manufacturing of a titanium knee produced 68% less carbon emissions compared with conventional methods [95].
Two LCA studies investigated the carbon footprint of telehealth or telemedicine services versus usual care. One compared the carbon footprint of patient evaluations before and after implementing a model of care that included telehealth for patients undergoing elective spinal surgery [91], and the other compared the carbon footprint of telemedicine versus in-person consultations for hand surgery rehabilitation [97]. Both studies reported significant reductions in carbon emissions when telehealth or telemedicine was used.
Three LCA studies explored the carbon footprint of various hand surgeries [83][84][85]. One compared the carbon footprint of open to endoscopic carpal tunnel release surgery [85]. This study reported a significantly larger carbon footprint for endoscopic surgery due to higher energy requirements from sterilising surgical instruments and longer operating times. Another study quantified the carbon footprint of surgical waste from different types of hand surgeries and concluded it could be reduced by reducing the number of surgical items in the operating room and better sorting of waste for appropriate disposal [84]. The third study estimated the carbon footprint of three hand surgeries (carpal tunnel release, open reduction and internal fixation of distal radius fracture or primary flexor tendon repair) based upon the practices of 35 surgeons [83]. They found significant differences in operating room waste for the same surgery dependent upon the individual surgeon's practices.
One LCA from Germany compared the environmental impact of disposable versus reusable instrument sets for lumbar spine fusion surgery [103]. It found that disposable sets had 45 to 85% less environmental impact largely attributable to the high energy consumption of steam sterilisation for reusable sets.
One LCA was an engineering-based case study that included a multi-criteria decision-making approach to compare the environmental impact of three knee supports manufactured from different materials [105]. It concluded that these methods are useful to identify and optimise new eco-friendly products.
One LCA study quantified the average carbon dioxide equivalent (CO 2 e) emissions of general, spinal and combination (general and spinal) anaesthesia used for knee replacements at a hospital in Melbourne, Australia using a 'cradle to grave' assessment [101]. This method measures the carbon footprint of a product from the resource extraction phase ('cradle') to its disposal ('grave'). As well as the anaesthesia, it included single-use items (e.g., plastics, glass, cotton etc.) and waste disposal. McGain et al. (2021) reported similar CO 2 e emissions for general, spinal, and combination anaesthesia when the parameters for the inhaled anaesthetic, including use of sevoflurane as the inhaled anaesthetic, were the same in those that received either general anaesthesia alone or a combination of general and spinal anaesthesia [101].
Their findings differed from another study performed in the US that found that the median CO 2 e emissions of general anaesthesia was significantly higher than spinal anaesthesia for single-level transforaminal lumbar interbody fusions (TLIF) [86]. This study performed a partial LCA using a 'cradle-to-gate' assessment, a method that only includes the carbon footprint of a product from the cradle to the moment that it is sold or received by the consumer ('gate'). Therefore, some large sources of CO 2 e emissions (e.g., single-use plastics, electricity for patient air warmer) were not included. Another point of difference was that the Australian study calculated CO 2 e emissions based on an electricity mix derived from 75% brown coal which has double the CO 2 e emissions than electricity produced in the United States [101].
One Danish simulation study measured the energy consumption of differing types of ventilation (ventilation system fans and warming/cooling coils) in operating theatres during mock total hip replacements [102]. They reported that reducing fresh air influx for laminar airflow systems by 50% led to significantly lower energy consumption without resulting in an unacceptable increase in bacterial counts.
The remaining 12 research studies measured waste associated with orthopaedic surgery [87-90, 92-94, 96, 98-100, 106]. One study estimated that average dry weight waste, of which textiles (e.g. bandages, disposable sheets) accounted for over half, could be reduced from 5.7 to 4.5 kg per cemented hip replacement by switching to customised operating kits containing less consumable materials, packaging and products [98].
A further nine hospital waste audits quantified the weight of waste of 205 orthopaedic operations, predominantly joint replacements [88,89,93,94,99,100,106], but also hip arthroscopies [92], facet joint injections [100] and open reduction and internal fixation (ORIF) for malleolus ankle fracture [96]. Three waste audits reported the volume of surgical waste and extrapolated data to estimate annual landfill from knee replacement surgeries in Canada [94], as well as the potential reduction of waste or CO 2 emissions from recycling programs [99] and waste segregation [106]. Non-recyclable waste was the largest waste stream for most orthopaedic operations [88, 89, 92-94, 96, 99, 100, 106].
One study found that combining a 'minimal custom' surgery pack with local anaesthesia rather than a standard surgery pack with sedation and local anaesthesia reduced average surgical waste by 13% for minor hand surgery [90]. The final study redesigned the operating set to include 23 rather than 35 instruments for hand surgery and implemented a waste recycling program that resulted in a 20 to 51% increase in monthly recycling rates across three hospital sites [87].
Editorials. Twenty-one editorial papers described a need to reduce environmental impact of orthopaedic surgery (n = 9) and focussed on disciplines responsible for managing musculoskeletal conditions (n = 12). Of those relating to orthopaedic surgery; three discussed a need for orthopaedic surgery to adopt sustainable practices [121,125,126]; two discussed strategies for reducing the environmental impact of hand surgery [120,122]; one focused on the benefits of regional anaesthesia in place of inhaled volatile anaesthetic gases [124]; one discussed the reuse of undamaged surgical screws or prostheses opened but not used during surgery [123]; one discussed recycling of metal implants posthumously [117]; and one reported the total weight of waste from 1,099 unspecified hand surgeries, but no methods were reported [127]. Of those discipline-specific editorials, nine discussed the environmental impact of physiotherapy and the role of the profession in reducing it [109-111, 113-116, 118, 119], two discussed how podiatrists can engage with the community to drive sustainable practice [107,108], and one outlined strategies for occupational therapists to approach climate change [112]. Narrative reviews. Two narrative reviews summarised environmentally sustainable changes that can be implemented for hand surgery [128,131]. One summarised 'Lean and Green' initiatives that aim to reduce waste-energy consumption, improve sterilisation techniques and reprocess single-use devices [128], and the other summarised changes to reduce the carbon footprint of hand surgery using a 'Reduce, Reuse, Recycle, Research, Rethink and Culture' framework [131]. Both reviews reported financial benefits from implementing environmentally sustainable hand surgery practices. There were four additional papers relating to these publications [87,90,94,127] (see Tables 1 and S3).
One narrative review on environmental sustainability in orthopaedic surgery, that identified all seven relevant studies that we included, highlighted a need for high-quality research on best practices for orthopaedic surgery to reduce its carbon footprint [129] (see Table 1). The remaining narrative review explored bioresorbable orthopaedic implants as a sustainable alternative to traditional permanent implants for some orthopaedic surgeries [130].

Discussion
Our scoping review identified 49 publications focused on the environmental impacts of health care for musculoskeletal conditions. Most papers were published within the last three years and almost half were editorials, likely reflecting an increasing interest in the topic. Almost three-quarters were related to orthopaedic surgery which is consistent within other health fields that have recognised surgery as a large contributor of greenhouse gas emissions [134][135][136]. Of the 24 included original research studies less than half directly measured the environmental impact relating to climate change for any aspect of musculoskeletal health care and none quantified the carbon footprint of well-recognised contributors of greenhouse gas emissions such as hospital stays, pharmaceuticals and imaging [4,55].
Our review identified some promising strategies for reducing the environmental impact of musculoskeletal health care including use of additive rather than subtractive manufacturing of orthopaedic components, greater use of telehealth, and reducing fresh air influx for laminar airflow systems in operating theatres, that warrant further investigation. The finding that open carpal tunnel release has a lower carbon footprint compared to endoscopic release, which may be preferred by the patient [137], indicates a need to consider these competing priorities. Similarly, while many studies identified ways of reducing waste in orthopaedic surgery including greater use of reusable instruments, the finding from one study that reusable instrument sets had a greater carbon footprint in comparison to disposable sets indicates that evidence of environmental benefit is required before introducing changes to practice.
To better understand the environmental impact of health care for musculoskeletal conditions there is a need to identify and quantify the impact of care in terms of a carbon footprint, and implement standardised and valid metrics for routine collection across multiple institutions and government bodies [138,139]. Collecting comparable carbon metrics associated with the delivery of musculoskeletal care such as CO 2 e emissions via life cycle assessment or the development of new carbon intensity metrics would facilitate accurate benchmarking, monitoring and transparent reporting of data that can be used to identify high emitters of greenhouse gases for targeting efforts to reduce them [138,139]. The methods for collecting these metrics are complex and, as exemplified by the different results in comparing general to spinal anaesthesia across countries and by use of different LCA methods (cradle to gate or to grave metrics), specialised expertise is needed to be able to explain such differences.
Nine of the original research studies included in this review were waste audits that provided some information regarding the weight, volume and type of hospital waste associated with orthopaedic surgeries. However, the estimates had low precision and poor generalisability as they were based on a small number of surgical operations ranging from one to 55. While larger studies performed across multiple hospital sites would provide more representative samples of the waste produced from orthopaedic surgeries, the UK National Health Service (NHS) estimates that waste produced across the NHS healthcare system accounts for only 3% of the total carbon footprint of health care [7]. Future research on the environmental sustainability of orthopaedic surgery may therefore have greater impact if directed towards larger contributors of greenhouse gas emissions. Additionally, there may be opportunity for existing waste audit data to be quantified as CO 2 e emissions estimates using retrospective life cycle assessment methods, although this process requires a high level of expertise and is resource intensive [139].
Environmentally sustainable health care is needed across all health systems to minimise the direct and indirect harms it may be causing to our planet and its population [140]. In addition to collecting meaningful data using standardised carbon metrics, a framework by MacNeill et al. (2021) proposes three principles for achieving health system sustainability that can be directly applied to musculoskeletal care [141]. The first principle involves reducing the demand for health services. While this has grown as a consequence of ageing populations and population growth, public health policies are needed that prioritise disease prevention which will have additional benefits beyond musculoskeletal health. The second principle is to better match the supply and demand of health care and health support services across populations and settings, while the third is to reduce greenhouse gas emissions from the delivery of health care. The latter could be achieved by de-implementation of low value care, particularly targeting low-value tests and treatments with large carbon footprints, as well as expanding low carbon services such as telehealth across health systems. Many of the publications included in this review align with this third principle, although more carbon metrics are needed to further determine the largest contributors of greenhouse gas emissions within musculoskeletal health care.
The main strength of this review is that we used scoping review methodology to identify a broad range of studies and editorials across multiple disciplines. We also developed a comprehensive environment-themed search strategy through discussion with environmental scientists and after examining systematic reviews that had explored environmental sustainability for health care in other fields [2,142]. We did this because we could not identify validated search strategies published for 'environmental health' or 'environmental impact'.
A limitation to our database search is that we used the search strategy for musculoskeletal conditions used by Cochrane Musculoskeletal [143,144], but this did not include broad anatomical terms (e.g. hand, wrist, elbow, shoulder etc.). To overcome this, we performed comprehensive Google and Google Scholar searches using anatomical, surgical, telehealth and environment themed keywords and also hand searched the reference lists of included publications to identify relevant publications and grey literature articles not published or indexed in biomedical databases. Our search identified narrative reviews that included 11 of our included original research studies and no additional relevant papers also minimising the likelihood of missing papers that would have appreciably altered our conclusions.

Conclusion
Despite an established link between health care and greenhouse gas emissions we found limited empirical data estimating the impact of musculoskeletal health care on the environment. Most of the studies we identified quantified the carbon footprint of aspects of orthopaedic surgery, particularly surgical waste, but there were limited data for other aspects of care such as imaging, pharmaceuticals and allied health care. Further data are needed to determine whether actions to lower the carbon footprint of musculoskeletal health care should be a priority and to identify those aspects of care that should be prioritised.